Non-invasive Positive Pressure Mechanical Ventilation: NIPPV: CPAP BPAP IPAP EPAP. My Real Goals. What s new in 2018? OMG PAP?

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1 Non-invasive Positive Pressure Mechanical Ventilation: What s new in 2018? Geoffrey R. Connors, MD, FACP Associate Professor of Medicine University of Colorado School of Medicine Division of Pulmonary & Critical Care Medicine NIPPV: CPAP BPAP IPAP EPAP OMG PAP? My Real Goals 1) Demystify non-invasive mechanical ventilation (NIPPV) 2) Allow you to better manage and make improved decisions regarding NIPPV when I m not around

2 Disclosures I have no financial connections to any company or product related to my talk today. Learning Objectives 1) Develop a shared appreciation for respiratory failure: recognition consideration of some form of mechanical ventilation invasive versus non-invasive 2) Foster an appreciation for the difference between continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP) Learning Objectives 3) Discuss the advantages and disadvantages of heated high flow nasal canula 4) Answer all your questions!

3 Question #1 Lots of patients present with shortness of breath or appear to have a high work of breathing. How do I know if my patient has true respiratory failure that I should intervene upon? Answer #1 Respiratory Failure Basic Definition of Respiratory Failure Respiratory Failure PaO2 < 55 mm Hg PaCO2 > 45 mm Hg and ph < 7.35

4 Intervening on Failure Can Be Simple Respiratory Failure FiO2 # of Alveoli Respiratory Rate (RR) Tidal Volume (Vt) Respiratory Failure FiO2 # of Alveoli Respiratory Rate (RR) Tidal Volume (Vt) Respiratory Failure FiO2 PEEP Respiratory Rate (RR) Tidal Volume (Vt)

5 Respiratory Failure FiO2 PEEP Respiratory Rate (RR) Tidal Volume (Vt) C = ΔV/ΔP ΔV = C ΔP Vt = Insp - Exp Respiratory Failure FiO2 PEEP Respiratory Rate (RR) IPAP - EPAP C = ΔV/ΔP ΔV = C ΔP Vt = Insp - Exp Question #2 Once I have decided that my patient is in failure, which machine do I choose, CPAP or BPAP?

6 We Already Answered This Mostly Respiratory Failure FiO2 PEEP Respiratory Rate (RR) IPAP - EPAP PEEP Matching PEEP Matching PRESSURE

7 PEEP Matching PRESSURE PRESSURE PEEP Matching PRESSURE + CPAP PRESSURE PEEP Matching PRESSURE + CPAP PRESSURE

8 Question #3 Let s start with a standard COPD patient. I recognized failure clinically and I ordered an ABG to look for hypercapnea. I know that 20% of COPD patients admitted to the hospital will go on to develop hypercapnic failure. When should I start NIPPV? COPD and NIPPV at the Door By the evidence, there s no defined role for CPAP in COPD exacerbations Starting early (before hypercapnea has developed): Does relieve dyspnea Offers no mortality benefit Demonstrates no difference in intubation rates (7% v. 8%) Is poorly tolerated Keenan SP et al. Resp Crit Care 2005 Bardi G et al, Eur Resp J 2000 COPD and NIPPV in Early Failure Using NIPPV when pre-intubation hypercapnea (ph = ) is present is VERY helpful Fewer ICU escalations Fewer infectious complications Improved hospital LOS Reduced intubations Improved dyspnea Improved survival Schmidbauer W et al, Em Med J 2011 Plant PK et al, Lancet 2000

9 COPD and NIPPV in Late Failure It s OK to try NIPPV if you think intubation is likely (ph < 7.2) unless: Arrest Periods of apnea Significantly altered mental status GCS < 7 medication-requiring agitation Bradycardia Hypotension COPD and NIPPV in Late Failure Those who get better quickly, do better; those who don t fair worse EARLY IMPROVERS NON-EARLY IMPROVERS No increase in mortality Prolonged hospital stay Decreased ICU LOS Prolonged ICU stay Reduced complications Less O2 on discharge Fewer readmission at 1 yr Fewer trachs Cheaper Conti G et al, Int Care Med 2000 Jurjevic M et al, Coll Anthropol 2009 Question #4 I did everything correctly but my patient just isn t getting better. When do I pull the trigger on intubation?

10 When to Intubate? Those who get better quickly, do better; those who don t fair worse Most improvement is seen within 1-4 hours Trend toward worse mortality in those who had delayed intubation (> 4 hours) Wood KA, et al. Chest 1998 Plant PK et al, Thorax 2001 Question #5 What about asthma? Does it respond the same as COPD? NIPPV and Asthma The evidence for NIPPV in asthma is far inferior to the evidence in COPD No randomized trials exist Meta analyses are fuzzy My recommendation: I wouldn t do it Rate is intubation are not decreased Mortality is not improved Those with delayed intubations do worse

11 Question #6 Moving on to a standard CHF patient. I recognized heart failure clinically and am worried about respiratory failure from pulmonary edema Is NIPPV valuable in this population? NIPPV and CHF at (before) the Door 6 good (but heterogeneous) trials of pre-hospital and early hospital use of NIPPV Reduced need for intubation Improved mortality No difference between CPAP and BPAP Thompson J et al, Ann Emerg Med 2008 NIPPV and CHF for Early Failure 30 reasonable to good trials for NIPPV in CHF in the hospital Clear evidence across the board Fewer intubations Improved mortality No increase in complications (i.e. heart attack) No evidence in cardiogenic shock No difference between CPAP and BPAP Good A et al, NEJM 2008

12 NIPPV and CHF for Late Failure No evidence in cardiogenic shock Question #7 Heated high flow nasal canula (HFNC) offers an alternative form of non-invasive ventilation. It is attractive in that patients can eat and talk while on it. But is it as good as CPAP? Is it as good as BPAP? How Does HFNC Work? HFNC provides CPAP ventilation Liter Flow PEEP 10L 0 20L 0 30L 3 40L 4 (5?) 50L 5 (7?)

13 How Does HFNC Work? It is the only NIPPV device that washes out deadspace! HFNC in Respiratory Failure FLORALI (2015) HFNC versus BPAP in acute respiratory failure (?ARDS) No worse in trials for COPD, CHF, periextubation Better tolerated My Recommendation: Call pulmonary and give it a try Question #8 What about special populations, like my bone marrow transplant or immune compromised cancer patients?

14 NIPPV in the Immune Compromised The #1 reason for ICU admission in the immune compromised is acute respiratory failure The data on CPAP and BPAP overlap Weaker evidence than our other groups Fewer ICU escalations Independent predictor of mortality Reduced intubations Reduced rate of nosocomial PNA Gristina GR et al, Crit Care Med 2011 Ask Me About All the Rest Post chest surgery Post abdominal surgery Post trauma Pandemic illnesses Following all extubations Following a high-risk extubation Age > 65 Known cardiopulmonary disease Following early extubation failure TABLE 2 Recommendations for actionable PICO questions Clinical indication # Certainty of evidence Recommendation Prevention of hypercapnia in COPD exacerbation Conditional recommendation against Hypercapnia with COPD exacerbation Strong recommendation for Cardiogenic pulmonary oedema Strong recommendation for Acute asthma exacerbation No recommendation made Immunocompromised Conditional recommendation for De novo respiratory failure No recommendation made Post-operative patients Conditional recommendation for Palliative care Conditional recommendation for Trauma Conditional recommendation for Pandemic viral illness No recommendation made Post-extubation in high-risk patients (prophylaxis) Conditional recommendation for Post-extubation respiratory failure Conditional recommendation against Weaning in hypercapnic patients Conditional recommendation for # : all in the setting of acute respiratory failure; : certainty of effect estimates:, high;, moderate;, low;, very low. Rochwerg et al. Eur Resp J 2017

15 COPD exacerbations Stage of ARF Not established Mild-moderate (early) Severe (late) High Extubation failure in high-risk hypercapnic patients (i.e. COPD) Weaning from invasive Immunocompromised patients ventilation (only COPD) ACPE Likelihood of NPPV success Moderate Post-abdominal surgery Post-operative lung resection Fibre-optic bronchoscopy Do-not-intubatate order Chest trauma CAP COPD exacerbations Pre-intubation oxygenation Low COPD exacerbations Extubation failure Hypoxaemic (ARDS) Asthma exacerbations Hypoxaemic (ARDS/CAP) Do-not-intubate order To prevent ARF To prevent intubation Alternative to invasive ventilation Goals of NPPV Scala R et al. Eur Resp Rev 2018 Thank You!